Factors Influencing Decision-Making in Pregnancy and Institutional Delivery

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Introduction: High rates of maternal mortality, estimated to be 176/100,000 in 2015, continue to be important challenges for Bangladesh, since a low percentage of women seek professional medical assistance for pregnancy related care, deliveries and complications. Therefore, it is important to examine the specific interpersonal relationships, and hierarchy of influencers associated with decision-making processes around seeking maternal health care within families and communities. Methods: The study was cross-sectional with a mixed-methods (i.e., quantitative and qualitative) approach. Study areas were selected following a multi-stage cluster approach for adequate inclusion of urban and rural areas across Bangladesh’s administrative divisions. Total 943 sample respondents included 317 pregnant women or who delivered in last one year, 312 husbands, 262 mothers-in-law and rest were elderly relatives. The qualitative component included service providers and community persons in those areas. Results: Women receive more information about maternal health and mostly from service providers. Husbands and mothers in law are the most influential (more than women themselves), however, they receive less information about maternal health. There is a prevalence of traditional attitudes among the older generation that may dissuade women from using maternal health services. In addition, both older and younger generations are somewhat influenced by societal values that stem from religious beliefs. Almost all (96%) of families own at least one mobile phone, over 25% receive different health information through mobile phones. Discussions: Statistical analysis showed that higher levels of educational attainment, living in urban area, and having received information about maternal health were significantly associated with use of ANC and institutional delivery services. The primary reasons for not utilizing maternal health services were not having had problems during pregnancy, financial constraints, family restrictions, attitudes based on sociocultural and religious beliefs, distance and transportation limitations, and poor treatment from service providers. These findings correspond to results from other studies conducted in the South Asia region. Additional reasons for not having institutional delivery includedfear of caesarean section, lack of availability of female doctors, feeling safe at home. Regional studies from rural Bangladesh, India and Pakistan document similar findings. Conclusions: Though women directly receive information about maternal health from service providers, and have higher levels of educational attainment than their relatives, they are not making the decision about whether to use maternal health services. There are opportunities to change specific attitudes and beliefs within families that do not support women’s use of maternal health services. Mobile phones present an underutilized opportunity for sharing maternal health information. Lessons learned: The significant association found in this study between having access to information and the choice to deliver in a health facility is key for future programs. It is recommended to provide focused communication messages to husbands and elderly family members. Additionally, influential community members need to be involved to reduce negative attitudes. Limitations: Although the research had a nationwide sample, the findings cannot be generalized to the whole population. Suggestions for future research: Intervention research on effectiveness of focused communication campaigns will help to promote utilization of maternal health services.